The Oregon ISP
Welcome to the Oregon Individual Support Plan (ISP) instructions. The Oregon ISP is the written details of the supports, services, and other resources a person will use to meet support needs and reach personal goals and outcomes.The ISP is created by the person’s Services Coordinator or Personal Agent (SC/PA) following a person-centered approach to planning.
The planning process begins well before the ISP gets written. The SC/PA and others invited by the personbegin by seeking to understand what is important TO the person from his/her perspective, including those things the person wants to do, learn, try, or have. These priorities and additional details the person chooses to share are recorded on the Person Centered Information document.
Support needs are assessed following a functional needs assessment process and any known, serious risks in the person’s life are identified. Conversation between the person and their SC/PA includes the person’s preferences for how support is delivered and who or what will provide the support.
The SC/PA brings this information together in the ISP to create an outline of the person’s desired outcomes, the person’s career development plan, any chosen services or community resources that will support the person to work toward their desired outcomes or meet assessed needs, as well as information about how any known, serious risks will be addressed.
Person Centered Information
Risk Identification Tool
One Page Profiles
Desired Outcomes
Career Development Plan
Chosen Services
Risk Management Plan
Other sections in the ISP
Making Changes
Resources
Each chapter of this manual highlights “What to expect in your role” for people with ISPs, families, legal or designated representatives, providers, services coordinators, and personal agents.Person Centered Information
Gathering and Recording Person Centered Information
Gathering Person Centered Information is one of the foundations of the ISP process. Person Centered information can help us understand what is important To and For a person, what priorities they have, what they want their life to look like and how they want to be supported. The Person Centered Information form provides a place to record information gathered from the person and others who know and care about the person.
Once complete, this document serves as a valuable record of perspectives gathered from the person and invited participants on a range of important topics. This information contributes to the developmentof an ISP that is meaningful to the person and reflects what they want their life to look like.
Information gathered here may result in powerful action in the ISP, such as:
- Desired Outcomes that the person wants to pursue
- Community resources and other informal supports the person may access
- Chosen services, including both paid and unpaid services.
These are just some examples of what to do with information recorded here. Not everything written on the Person Centered Information document must be recorded in the ISP. ISP teams should carefully review the information gathered and work together to decide what needs to be included in the ISP.
Adult and Youth versions
The Person Centered Information document is available in both Adult and Youth versions. The Youth version has supporting questions under each topic that are designed to address issues relevant for those under age 18. The youth version also includes a field to record the young person's date of birth.
Perspectives
The form includes space to record multiple perspectives from those participating in the person-centered information gathering process.
Person's perspective
This is the place to capture the person’s perspective. The person’s perspective includes those things that are important To the person. Things that are important To the person might include the things they like and love, the things and people they want and don’t want in their life, and the things that work and don’t work for them.
The person’s perspective is learned over time in a variety of ways:
- The person’s words (spoken words, signs, written word, assistive device), if any
- Actions that we observe
- Information shared by others who know the person well.
Family and/or guardian's perspective
This section appears automatically on the Youth version of this document. It can be toggled on for adults who have a guardian or who choose to have family involved in planning, or their perspectives can be recorded in the "Additional input" sections of this form.
If the person has a legal guardian, include their perspective in this section. For adults, the legal guardian's perspective may also be recorded in "Additional input," if desired.
Family relationships take many different forms and are not limited to blood or legal relations. It may include anyone the person chooses to identify as family.
Additional input
This is the place for all other perspectives from people the person chooses to haveinvolved in planning. This includes paid support providers or other professionals in the person's life such as counselors, therapists, medical professionals, behavior professionals, and more.
When there are multiple perspectives on a similar issue, consider recording from whom each perspective was shared. Attributing information to its source can make it easier to follow-up if more information is needed later.
What to expect in your role
The person & their legal or designated representative
Prior to the ISP Meeting
You can expect to be asked to share your perspective about a number of topics in your life. You are in charge of who you share this information with and how much information you share. If you don't want to talk about a particular topic, you don't have to. You may invite anyone else to contribute information, such as friends, family, or providers.
Your SC/PA will ask you, your legal or designated representative(if any), or the people you've chosen to help you plan, to share perspectives about your life.
If you are supported by a provider in a residential setting
Your residential provider will ask you to share your perspective. Your provider will also record their perspective on this document in the section marked Additional input.
If you need help sharing your perspective
You can choose someone else to help you communicate your perspective. If you are unable to choose someone, your ISP team may choose someone who knows you well to help you. They will indicate who helped you in the space provided at the end of the form.
Provider organizations & Foster providers
Prior to the ISP Meeting
Residential providersmust gather information,then review and update this document at least every twelve (12) monthsprior to the ISP meeting.Share the updated copy with the person's SC/PA prior to the ISP meeting.
Gather information from the person's perspective and from others that the person chooses. If you don't have information about certain topics or the person declines to discuss, note that.
Carefully record the person's perspective in the space provided. Whenever possible, include the person's own words.
If the person needs support to communicate their perspective, ask the person who they want to help them communicate their perspective. If the person is unable to identify someone to support them, the ISP team may identify someone who knows the person well to contribute their knowledge of the person's perspective.
If you have been asked to assist the person to record or communicate his/her perspective, you must record the person's perspective faithfully. This is true, even if you disagree with the person’s perspective or feel the things that are important to them are unsafe or unhealthy.
Accurately record who contributed to this document in the space provided at the end of the form.
Use the information shared by the person and by others to identify areas of focus for the coming year. Consider drafting action plans toward desired outcomes that are meaningful to the person.
Throughout the Year
Keep a copy of the updated Person Centered Information document in your files.
Use the information on the Person Centered Information to tailor the services you provide toward the person's priorities. When new support staff are hired, train them on the contents of this document.
Watch for any circumstances where supports you provide are in conflict with something that is important to the person. If this happens, take steps to adapt your supports to the person's preferences. If you're unable to do this, discuss this with the person and their SC/PA.
You may update the information contained in this document any time during the year. When you make changes, follow the documentation procedures in place at your organization. No change form is needed to change this document.
SC/PAs
Prior to the ISP Meeting
Information must be gathered and this document must be reviewed and updated at least every twelve (12) months prior to the ISP meeting.
Ask the person, his/her guardian, or the people they have chosen to help plan to share perspectives about the topics on this document.
Gather information from the person's perspective and from others that the person chooses. If you don't have information about certain topics or the person declines to discuss, note that.
Carefully record the person's perspective in the space provided. Whenever possible, include the person's own words.
If the person needs support to communicate their perspective, ask the person who they want to help them communicate their perspective. If the person is unable to identify someone to support them, the ISP team may identify someone who knows the person well to contribute their knowledge of the person's perspective.
If you have been asked to assist the person to record or communicate his/her perspective, you must record the person's perspective faithfully. This is true, even if you disagree with the person’s perspective or feel the things that are important to them are unsafe or unhealthy.
Accurately record who contributed to this document in the space provided at the end of the form.
If the person is supported by a provider in a residential setting, the residential provider must complete or update this document with information they have available to them. You should receive a copy of this document from the residential provider prior to the scheduled ISP meeting. If the person invited other providers to contribute, you may receive additional documents. If there are multiple documents from different providers, they do not need to be merged, but can be filed together with the completed ISP in your records.
Review the person centered information. Consider the following points as you review:
- Identify priorities or topics that the person may want support to work toward over the next ISP year.
- Make sure the person's perspective is carefully and accurately recorded even if others disagree with the person’s perspective or the things that are important to the person are unsafe or unhealthy.
- Look for situations where there may be conflict between the person's perspective and someone else's.
Watch for issues to include in the new ISP, discuss at ISP team meeting, or have a separate conversation with those involved.
Throughout the Year
Keep a copy of the updated Person Centered Information document in the person’s file.
Familiarize yourself with the information on the Person Centered Information. When monitoring or checking in on the person throughout the year, listen and observe for evidence that the person's perspective is being recognized and addressed.
You may update the information contained in this document any time during the year following documentation practices common at your organization. No change form is needed to change this document.
Risk Identification Tool
The Risk Identification Tool is designed to assist teams in identifying any known, serious risks that are present in the person's life. The tool includes many common risk factors or warning signs in order to help teams recognize when a risk is present.
Serious RiskFor purposes of this tool, serious risks are considered things that would likely result in hospitalization, institutionalization, serious financial hardship, legal action, or place the person or others in imminent harm unless specific, individualized support is necessary to address it.
Once any risk is identified, the SC/PA discusses it with the person and his/her ISP team to identify the best way to address it. Every risk marked 'Yes' will be listed by the SC/PA on the person's ISP Risk Management Plan along with a description of what supports are available in the person's life to address it. Read more about the ISP Risk Management Plan on page 31.
This document is best completed or reviewed near the time of the needs assessment as similar information is covered. However, be mindful of changing risks throughout the year. While this tool must be completed initially prior to the ISP meeting, it must also be updated throughout the year if known risks change.
The complete Risk Identification Tool is kept in the person’s file at the CDDP or brokerage.
What to expect in your role
The person & their legal or designated representative
You can expect to be asked to share your perspective about any serious risks that you believe are present in your life.
If you are supported by a provider in a residential setting
Your provider will also share information they are aware of with your SC/PA.
If you need help sharing your perspective
You or your legal or designated representative can choose someone else to help you record your perspective. Let your SC/PA know if you want help sharing your perspective.
Provider organizations & Foster providers
Prior to the ISP Meeting
Familiarize yourself with the risks and risk factors in the Risk Identification Tool.You must share information with the person's SC/PA about any known, serious risks in the person's life. Communicate any evidence of known, serious risks promptly to the SC/PA. Maintain documentation about this communication.
Talk with the SC/PA to find out the best way to share that information.
Throughout the Year
Prepare and maintain a “Provider Risk Management Strategies” form specific to the location where you support the person. This should include all of the risks listed on the Provider Service Agreement or ISP Risk Management Plan that are directed to you to support.
If the SC/PA disagrees or does not include a risk on the ISP Risk Management Plan that you believe may be a serious risk, discuss it further with them. Provide evidence of the issue you are concerned about and document any discussions you have with the SC/PA. Follow your agency’s policies or guidance for resolving issues and disputes between agencies as needed if you feel the difference of opinion puts the person’s health and safety at risk or does not respect the person’s preference.
Notify the person's SC/PA if you observe new or changing serious risks in the person's life. Identify strategies you can offer to help address these risks and discuss those strategies with the person and the SC/PA.
SC/PAs
SC/PAs have the responsibility for the accurate completion of the Risk Identification Tool based on available information.
Complete this form based on information learned through conversations, file review and your knowledge of the person.
Upon entry into services, identify serious risks during or near the time of the needs assessment. That way, you can use the information that was discussed during the needs assessment and you don’t have to repeat conversations that may feel intrusive to the person or their family.
Prior to the ISP Meeting
This document must be reviewed at least annually prior to the ISP meeting.
- If the person lives in his/her own home or their family home, ask the person, his/her legal or designated representative, or the people they have chosen to help plan if there are any changes in serious risks in the person's life. If you are also conducting the needs assessment for the person, check in on this information at the same time to avoid redundant conversations with the person and his/her designated representative(s).
- Providers are expected toshare any updates they have about changes in risks in the person's life. Communicate with the provider to make agreements about how that information should be shared with you.
Throughout the Year
- Provide a copy of this tool to the person or his/her designated representative. Keep a copy of the most current Risk Identification Tool in the CDDP or brokerage files.
- Familiarize yourself with the known, serious risks present in the person's life. When monitoring or checking in on the person throughout the year, listen and observe for evidence that those risks are being effectively supported.
- If this document needs to be updated, you may do so by completing a change form. Other team members may also initiate a change form and send it to you for review.
- Continue to keep this form up-to-date throughout the year if you learn about changes in risks in the person's life.
Completing the form
Final responsibility for completing this document rests on the SC/PA. Providers who support the person are expected to communicate with the SC/PA promptly if they observe any changes related to serious risks in the person’s life.